APD > Fight Medicaid Fraud

Fight Medicaid Fraud

Persons who report Medicaid fraud may be entitled to a reward up to 25 percent of the amount recovered, or a maximum of $500,000 per case, if a criminal case results in a fine, penalty or a forfeiture of property. Tips about suspected fraud can be reported by calling the Attorney General's Fraud Hotline at 1-866-966-7226 or the Agency for Health Care Administration's Consumer Call Center at 1-888-419-3456. Citizens may also report fraud on-line by visiting the AHCA web site, http://ahca.myflorida.com and clicking the "Report Fraud" button.

Examples of Fraud and Abuse

  • Billing for Services Not Provided; filing a claim for a service that was not actually provided to a consumer
  • Upcoding; filing a claim for a higher level of service than was actually provided
  • Self-Dealing/Kickbacks; accepting items of value for improper favoritism toward a provider or consumer

False Claims

  • The Florida False Claims Act (Chapter 68, Florida Statutes) mirrors the federal law allowing false claims whistleblowers to receive up to 25 percent of any recovery
  • False claims whistleblowers, called "relators," can sue for themselves and the affected state agency
  • The Department of Legal Affairs (Attorney General) and the Department of Financial Services both receive and review false claims lawsuits

APD Policies

APD works closely with the Florida Agency for Health Care Administration and the Florida Attorney General's Office to identify improper Medicaid claims and to maintain Medicaid program integrity in services provided to Floridians with developmental disabilities.

APD currently performs reviews of Medicaid claims as follows:

  • A regular review of paid Medicaid claims for individuals served by APD is conducted by the agency. APD utilizes more than 60 separate review procedures relative to processing Medicaid claims. Based on these reviews APD, in conjunction with AHCA and the Attorney General's Office, carries out or oversees Medicaid recoupment for improper claims.
  • For the APD private provider sector, performance of Medicaid billing and claims audits is conducted as part of a fiscal review by an agency contractor. Approximately 170 onsite provider reviews are conducted each year. Where Medicaid claims without adequate supporting documentation are identified, audit-based recoupments of funds are taken in conjunction with AHCA.
  • Upon receiving reports of possible Medicaid fraud or abuse, APD auditors conduct an initial review. Auditors may refer allegations to the APD Inspector General, to AHCA Medicaid Program Integrity or to the Attorney General's Medicaid Fraud Control Unit.
  • For the APD services, APD conducts routine reviews of documentation supporting Medicaid claims. The APD Inspector General's Office also conducts program and facility audits under its oversight authority.

APD provides training and support of this requirement as follows:

  • APD issues Administrative Memoranda that specify the billing standards and service documentation requirements for each Medicaid service and program operated or certified by APD.
  • APD conducts training sessions throughout the state on Medicaid billing standards and documentation requirements for state staff and staff of not-for-provider agencies.

False Claims Act

The federal False Claims Act (FCA) permits the government and private citizens to sue anyone who submits a false claim to the Agency for Persons with Disabilities. The purpose of the FCA is to recover taxpayers' money that was fraudulently paid to individuals who deceived the government.